Nikan Zargarzadeh

Background: Placenta previa (PP) is a well‐recognized obstetric complication with established maternal risks, particularly hemorrhage, that contribute significantly to maternal morbidity. In contrast, low‐lying placenta (LLP) has historically been grouped with previa in both coding and clinical practice, limiting our ability to study its imparted associated outcomes as a distinct entity. However, in 2017, coding revisions allowed for a parsed diagnosis of LLP and PP and enabled the current study of differentiated associated outcomes. Objective(s): To describe and compare the independent rates of hemorrhage and severe maternal morbidity (SMM) associated with LLP and PP relative to normal placentation. Methods: We conducted a retrospective analysis using the Nationwide Readmissions Database (NRD) from 2017 through 2019, reflecting the initial 3 years of coding for LLP. Patients with multifetal gestation, ectopic/molar pregnancies, and other placental abnormalities were excluded. The primary outcome was hemorrhage, defined using international classification of diseases (ICD)‐10 codes for ante‐, intra‐, and postpartum hemorrhage (PPH). SMM was defined using the Centers for Disease Control and Prevention's index, which includes a range of life‐threatening complications such as disseminated intravascular coagulation, hysterectomy, and shock. Baseline characteristics and maternal outcomes were compared using chi‐square tests for categorical variables and Kruskal–Wallis tests for continuous variables. Multivariable regression analysis was used to evaluate the risk ratios (RRs) of adverse outcomes across these groups. Results: Among 5,625,432 singleton deliveries, 11,486 were diagnosed with LLP and 21,356 with PP. Compared to normal placentation, LLP was associated with a significantly higher rate of hemorrhage (21.1% vs. 4.0%, p < 0.001), SMM (4.5% vs. 1.8%, p < 0.001), maternal blood transfusion (3.3% vs. 1.1%, p < 0.001), hysterectomy (0.2% vs. < 0.1%, p < 0.001), and hysterectomy within 30 days (0.2% vs. 0.0%, p < 0.001). LLP was also associated with longer median hospital stay (3 vs. 2 days, p < 0.001) and higher total charges ($21,410 vs. $17,024; p < 0.001). In adjusted analyses using normal placentation as the referent group, LLP remained independently associated with hemorrhage (adjusted relative risk [aRR], 4.72; 95% CI, 4.56–4.89), SMM (aRR, 2.16; 95% confidence interval [CI], 1.99–2.35), and transfusion (aRR, 2.61; 95% CI, 2.36–2.88). PP was associated with even higher risks of hemorrhage (aRR, 8.93), SMM (aRR, 4.22), and transfusion (aRR, 5.69) compared to those with normal placentation (all p < 0.001). Conclusion: With the institution of distinct coding for LLP in 2017, we were able to distinguish between patients with LLP and PP. While PP remains associated with the highest risk of poor maternal outcomes, patients with an antenatal diagnosis of LLP also have an increased risk of hemorrhage and SMM relative to those with normal placentation. These findings should be considered during the prenatal counseling and management of patients with LLP.

Background: Progressive ventriculomegaly and the resulting irreversible brain damage may be mitigated through timely diversion prenatal intervention. While ventriculosubgaleal shunt (VSGS) is commonly performed postnatally in premature infants, in utero placement is unexplored. Objectives: We evaluated the feasibility of intrauterine placement of VSGS using a fetal lamb obstructive hydrocephalus model. Study Design: Hydrocephalus was induced in 14 fetal lambs by injecting 1–1.5 mL of BioGlueⓇ into the cisterna magna between Days 80 and 90 of gestation. Ten to 16 days later, ultrasound was performed to confirm hydrocephalus. Afterward, VSGS was surgically placed by creating a fetal subgaleal pocket, inserting a standard ventricular catheter, tunneling under the scalp, and securing with a silk suture, with the other end into a lateral ventricle. Near term, the ewes were sacrificed. Hysterotomy was performed to extract the lambs. Lambs were evaluated through gross inspection. Postmortem magnetic resonance imaging and pathology evaluations were performed. To assess the presence of activated microglia and astroglia, selected brain sections were immuno‐stained with ionized calcium‐binding adaptor molecule 1 (Iba1) and glial fibrillary acidic protein (GFAP), respectively. Results: Ten ewes with 14 fetuses (four twins) underwent hydrocephalus induction (median 86 days) by maternal laparotomy and either hysterotomy (two out of 14) or transuterine (12 out of 14) methods. Two fetuses were found demised at the time of shunt placement; hydrocephalus was confirmed in 11/12 surviving fetuses (three severe, four moderates, and four mild). A VSGS was successfully placed in all 12 surviving fetuses (median 104 days) employing open uterus fetal surgery. After shunt placement, one case died immediately from severe hydrocephalus, three were aborted, and one intrauterine fetal demise was found during cesarean delivery. Of the remaining seven lambs, seven out of seven VSGS remained under the scalp without catheter migration, and all demonstrated full scalp healing. Pathologic analyses by gross and histological methods confirmed typical hydrocephalic changes, including altered and denuded ependyma. However, more than half of the catheters were macroscopically obstructed with tissue debris and fibrin (four out of seven). Conclusion: Prenatal placement of the VSGS was technically successful in all cases, meaning the shunt could be inserted in 100% of fetuses. Survival to cesarean delivery was 58% (seven out of 12). Among survivors, no hardware migration or scalp breakdown occurred. Future studies should further explore the safety of the shunt.

Objectives: Prenatal ultrasound identifies polyhydramnios in approximately 0.7 % of pregnancies. Polyhydramnios (defined as amniotic fluid index >24 cm) is associated with maternal symptoms and preterm delivery. However, amnioreduction (AR) can effectively alleviate symptoms and reduce preterm delivery risks; its advantages remain controversial. This study aims to assess maternal safety following AR in singleton pregnancies systematically. Methods: Databases searched included PubMed, Embase, Scopus, and Web of Science until April 2024. Pregnant patients with singleton pregnancy and polyhydramnios undergo AR included in our study. Statistical analyses were conducted using R software. Results: From 574 initially identified articles, seven studies with 390 singleton pregnancies who underwent AR were included. The primary outcomes showed low odds of placental abruption 0.04 (95 % CI: 0.02–0.09, I²=12 %) and chorioamnionitis 0.03 (95 % CI: 0.01–0.08, I²=0 %). Secondary outcomes indicated a mean gestational age at birth of almost 36 weeks (95 % CI: 35.51–36.41, I²=49 %) and low odds of cesarean delivery 0.45 (95 % CI: 0.30–0.61, I2=58 %), preterm delivery within 48 h after AR 0.10 (95 % CI: 0.07–0.15, I²=9 %) and PPROM within 48 h after AR 0.03 (95 % CI: 0.02–0.04, I²=0 %). Conclusions: This study demonstrates that maternal complications are expected to be low following the AR procedure. However, given the lack of evidence for fetal benefit and pregnancy prolongation, future studies should directly compare the effects of AR with expectant management. Additionally, fetal survival is likely influenced more by the underlying fetal diagnosis or the etiology of polyhydramnios rather than AR itself. The current meta-analyses will serve as a guide for shared decision-making, and highlight the need for continued clinical trials powered to establish superiority or benefit with AR for singleton pregnancies.

Background: This study aimed to assess the comparative efficacy of monotherapy and combined therapy of cholinesterase inhibitors plus memantine on cognition in AD and determine efficacy across doses for these pharmacological drugs.Method: The screening of 2,113 articles were initiated. Finally, forty randomized controlled trials (RCTs) from PubMed, Web of Science, and Scopus databases inception to the end of Dec. 2022 were finally included in this review. The included RCTs contain donepezil, rivastigmine, galantamine and memantine alone or in any combination of them were compared with placebo in terms of MMSE score. The mean difference (MD) in MMSE score was considered as the effect size of efficacy. The quality of the RCTs were appraised using the Cochrane risk‐of‐bias tool (RoB‐2). An additive network meta‐analysis (NMA) was applied to compare the efficacy of the drugs. Trends of efficacy across doses for each available treatment were checked using a dose‐response modeling. Finally, P‐score as a probability of being the most effective treatment, was used to rank the treatments. All statistical analyses were done using netmeta and dosresmeta R packages. The study protocol was registered in the PROSPERO (CRD42022358469).Result: These RCTs included 16,785 AD patients with mean age 73 (SD = 3.5) yrs., and weight 64.5 (SD = 5.55) kg. Of these patients, 65.15% were women. The median follow‐up time was 6 (range = 3‐48) months. The main NMA results showed that galantamine 32mg/day (MD = 3.71; 95% CI = 2.21, 5.21; P‐score = 0.89), donepezil 10mg/day combined with memantine 20mg/day (MD = 3.27; 95% CI = 1.79, 4.76; P‐score = 0.83), and then galantamine 24mg/day (MD = 3.02; 95% CI = 2.19, 3.84; P‐score = 0.79) were significantly the most effective treatments compared with placebo, respectively. According to the sub‐group analysis of stages, donepezil 10mg/day combined with memantine 20mg/day (MD = 4.78; 95% CI = 2.86, 6.71) and galantamine 32mg/day (MD = 3.81; 95% CI = 2.20, 5.34) were recommended for moderate to severe and mild to moderate AD patients, respectively. Moreover, we found there was a significant positive linear trend of efficacy across doses of galantamine.Conclusion: Monotherapy with a high dose of galantamine or the combination of donepezil plus memantine have the most favorable effects on cognition for 6 months follow up in AD patients.

To investigate the outcomes of asymptomatic stage I twin‐to‐twin transfusion syndrome (stage I TTTS) among patients treated with fetoscopic laser photocoagulation (FLP) versus expectant management. Databases such as PubMed, Web of Science and Scopus were systematically searched from inception up to March 1st, 2022. The primary outcome was at least one fetal survival at birth and secondary outcomes included gestational age at delivery, preterm premature rupture of membranes < 32 weeks, preterm birth < 32 weeks, and single and dual fetal survival. Five studies were included in the meta‐analysis. There was no significant difference in terms of at least one survival (odds ratio (OR) = 1.40, 95%CI= (0.26, 7.43), P = 0.70), single survival (OR = 0.87, 95%CI= (0.51, 1.48), P = 0.60) and dual survival (OR = 1.63, 95%CI= (0.74, 3.62), P = 0.23) among FLP and expectant groups. Gestational age at delivery (mean difference = 1.19, 95%CI= (−0.25, 2.63), P = 0.10), the risk of PTBP = 0.65), and pPROMP = 0.44) were also comparable between the groups. Routine FLP of the placental anastomoses before 26 weeks of gestation is unlikely to be beneficial among asymptomatic stable stage I TTTS patients without cervical shortening as the procedure does not offer a survival advantage compared with expectant management.

This systematic review and meta-analysis assessed the risk of inadequate prenatal care and pregnancy outcome among incarcerated pregnant individuals in the United States. PubMed/MedLine, Embase, ClinicalTrials.gov and Web of Science were searched from inception up to March 30th, 2022. Studies were included if they reported the risk of inadequate prenatal care and/or pregnancy outcomes among incarcerated pregnant individuals in the United States jails or prisons. Adequacy of prenatal care was quantified by Kessner index. The random-effects model was used to pool the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals (CIs) using RevMan software. Nine studies were included in the final review. A total of 11,534 pregnant individuals, of whom 2,544 were incarcerated while pregnant, and 8,990 who were matched non-incarcerated pregnant individuals serving as control group, were utilized. Compared to non-incarcerated pregnancies, incarcerated pregnant individuals were at higher risk of inadequate prenatal care (OR 2.99 [95% CI: 1.60, 5.61], p<0.001) and were more likely to have newborns with low birthweight (OR 1.66 [95% CI: 1.19, 2.32], p=0.003). There was no significant difference between incarcerated and matched control pregnancies in the rates of preterm birth and stillbirth. The findings of the current systematic review and meta-analysis suggest that incarcerated pregnant individuals have an increased risk of inadequate prenatal care. Considering the limited number of current studies, further research is indicated to both assess whether the risk of inadequate prenatal care has negative impact on prenatal outcomes for this population and to determine the steps that can be taken to enhance prenatal care for all pregnant individuals incarcerated in the United States prisons.

Non-melanoma skin cancer (NMSC) is the most common cancer among white-skinned people. The main environmental risk factor for all types of skin cancer is ultraviolet (UV) exposure to the sun. However, significant modifiable risk factors, such as diet, have been studied about NMSC risk. Several original studies have been conducted on the link between various dietary components and the risk of NMSC in the past decade, but have not been systematically reviewed. This review focuses on the potential impact of dietary components in the prevention of NMSC and evaluates the findings of epidemiologic evidence for dietary factors. We conducted a systematic search of three databases, including Scopus, ISI Web of Science, and PubMed, to identify relevant epidemiological studies published between 2000 and July 6, 2021. Finally, forty-three articles were included. Because of the inherent limitations of epidemiological studies, no definitive conclusions can be drawn; however, the links between folate, citrus, caffeine, and alcohol with BCC are notable; thus, high dietary folate intake, as well as citrus and alcohol consumption, are associated with an increased risk of basal cell carcinoma (BCC), whereas caffeine is associated with a lower risk. More research is required to reach a definitive conclusion.